Prescription Sharing, Adolecent

ARTICLE IN PRESS

Journal of Adolescent Health - (2009) 1–4

Adolescent health brief

Prescription Medication Sharing Among Adolescents: Prevalence, Risks, and Outcomes Richard C. Goldsworthy, Ph.D.a,*, and Christopher B. Mayhorn, Ph.D.b a The Academic Edge, Inc., Bloomington, Indiana North Carolina State University, Raleigh, North Carolina Manuscript received April 2, 2009, manuscript accepted June 16, 2009 b

Abstract

We interviewed 594 adolescents throughout the United States. One in five reported sharing prescription medication. Of these, less than half received instructions, many delayed professional care, few informed providers, and a third reported experiencing side effects. Efforts to reduce medication sharing prevalence and risks among adolescents may be justified. Ó 2009 Society for Adolescent Medicine. All rights reserved.

Keywords:

Prescription medication sharing; Loaning; Borrowing; Diversion; Prevlaence; Risks; Adolescents

Prescription medication sharing has received heightened attention as a public health concern, with approximately one-third of the U.S. population self-reporting this behavior [1]. Several researchers have suggested diverse personal and societal consequences associated with such sharing, including exposure to side effects, delayed care, and increased antibiotic resistance (Figure 1) [1–3]. Despite indications that adolescents are engaging in this potentially risky behavior [1,4,5], few efforts have directly investigated sharing among adolescents [1,2,4–7]. Boyd and colleagues [8], for example, reported girls (27.5%) and boys (17.4%) frequently gave away their abusable prescription medications (i.e., sleeping, sedative or anxiety, stimulant, and pain medications). Poulin [7] reported that Canadian youth (n ¼ 13, 549) had given away (14.7%) or sold (7.3%) prescription stimulants. Daniel and colleagues [5] found girls and young women borrow (10%) prescription acne medication, a practice that entails teratogenic risk [9,10]. No studies to date, however, have broadly examined prevalence of adolescent prescription medication sharing, types of medications shared, and consequences of such sharing. Our research specifically examines a wider range of loaning and borrowing behaviors and associated consequences among adolescents.

*Address correspondence to: Richard C. Goldsworthy, Ph.D., Academic Edge, Inc., 108 E. 14th Street, Bloomington, Indiana 47408. E-mail address: [email protected]

Method Prescription medication sharing behaviors and consequences were assessed through interviews conducted in malls, parks, and public streets in 11 U.S. urban and suburban locations. Five hundred ninety-four (>50/location) demographically diverse adolescents aged 12-17 (mean ¼ 14.8, SD ¼ 1.7) were approached individually, had the study explained to them, provided written consent, and were screened for eligibility based on age. Eligible adolescents were interviewed verbally in English or Spanish by field researchers with experience in each recruitment location, and provided a $10 gift certificate and a parental notification letter. Interview questions were drawn from a previous study conducted among adults, pilot tested among a small group of adolescents, and modified. The following behaviors and consequences were investigated: 1. Have you ever borrowed prescription medication? 2. Have you had ever loaned prescription medication? Participants who indicated loaning or borrowing were asked these questions: 1. Which kinds of medicine did you borrow (and which did you loan)? 2. Did you receive (or provide) written or verbal warnings and instructions? 3. Did you borrow medicine rather than visit a healthcare provider? 4. Did you end up going to a doctor anyway?

1054-139X/09/$ – see front matter Ó 2009 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2009.06.002

ARTICLE IN PRESS R.C. Goldsworthy and C.B. Mayhorn / Journal of Adolescent Health - (2009) 1–4

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Figure 1. Enhancement of original medication-sharing impact framework (adapted from Goldsworthy et al., 2008).

5. Did you tell the doctor about borrowing? 6. Have you experienced an allergic reaction or side effect when borrowing prescription medications? Descriptive statistics and inferential analyses were generated in SPSS (SPSS Inc., Chicago, IL). Results Loaning prescription medications One in five participants (122 of 592, 20.5%) reported loaning prescription medication (Table 1), with allergy medications and pain relievers most commonly loaned. Among loaners, 47.5% reported providing printed instructions and 55.7% reported providing verbal instructions. Results did not significantly vary by participant characteristics; however, blacks were more likely to report loaning medication and were specifically more likely to loan allergy medications or birth control. Borrowing prescription medications Borrowing was similar to loaning: one in five (115 of 592, 19.4%) had borrowed prescription medication. Specific medication borrowing rates mirrored those for loaning. Half the borrowers reported receiving written and/or verbal instructions or warnings at least once. Nonnative English speakers were half as likely to report receiving verbal instructions. Borrowing did not vary by gender or age, blacks were more likely to borrow allergy medications, and those who spoke a language other than English were less likely to report borrowing allergy medicines. Impact on care Seventy-four percent (74%) of borrowers reported doing so rather than making an appointment with a healthcare

provider. Of these, 32.4% eventually visited a healthcare provider for the unresolved problem, with young women being more likely than men to do so. Forty percent of the adolescents who visited providers after borrowing medications failed to mention the medication borrowing to the provider (28 participants, 4.7% of the overall sample). Finally, 37.4% of borrowers (43 participants overall) reported experiencing a side effect. Discussion Approximately 20% of adolescents have shared prescription medication. This is troubling, because sharing presents a number of potential risks (Figure 1). Adolescents are sharing antibiotics, which may exacerbate bacteriologic antibiotic resistance: neither those loaning nor those borrowing are likely to have completed a full regimen. Adolescents are sharing acne medication, a class of pharmaceutical that includes a well-known teratogen. Previous findings regarding adolescents’ sharing of abusable prescription medications are confirmed [7,8]. Participants reported frequently not providing or receiving instructions or warnings. Such omission increases risk for incorrect medication usage. Three-fourths of participants borrowed to avoid a healthcare provider visit. A third of these participants reported eventually visiting a provider because the borrowed medicine did not resolve the initial problem. Avoided or deferred care can lead to delayed diagnosis and treatment and potentially increase sequelae, morbidity, and mortality. Patient disclosure of medication borrowing was reported in less than 50% of the cases, indicating that providers may need to specifically ask about borrowing. Finally, self-report of side-effects was surprisingly high (almost two of five borrowers). All sites were urban and suburban, which limits generalizability. Nonetheless, this is an improvement over previous

Table 1 Prevalence of medication sharing behaviors and related outcomes Gender

Age

Race

Home Lang

Male

Female

12-14

15-17

Caucasian

Black

Hispanic

Other^

English

Other

Base No.(%) Loaning Behaviors Have you previously loaned prescription medicine(s)? Which types of medicine have you loaned? Allergy medications (like Zyrtec, Clarinex, Flonase, etc.) Pain medications (like Darvoset, Oxycontin, etc.) Mood medications (like Paxil, Zoloft, Valium, Ritalin, etc.) Antibiotics (like Amoxicillin, Doxycycline, Bactrim/Spectra, etc.) Acne Medication (like Accutane) Birth control pills Have you provided printed instructions or warnings when loaning? Have you provided verbal instructions or warnings when loaning? Borrowing Behaviors Have you previous borrowed prescription medicine(s)? Which types of medicine have you borrowed? Allergy medications (like Zyrtec, Clarinex, Flonase, etc.) Pain medications (like Darvoset, Oxycontin, etc.) Mood medications (like Paxil, Zoloft, Valium, Ritalin, etc.) Antibiotics (like Amoxicillin, Doxycycline, Bactrim/Spectra, etc.) Acne Medication (like Accutane) Birth control pills Have you been given printed instructions or warnings when borrowing? Have you been given verbal instructions or warnings when borrowing? Have you ever borrowed instead of making an appointment with a healthcare provider? Did you end up going to a healthcare provider after trying the borrowed medicine? Did you NOT tell the healthcare provider about borrowing the medicine? Have you ever had an allergic reaction or other side effect when you borrowed?

594 (100)

289 (100)

305 (100)

249 (100)

345 (100)

293 (100)

129 (100)

123 (100)

49 (100)

501 (100)

83 (100)

122 (20.5)

60 (20.8)

62 (20.3)

53 (21.3)

69 (20.0)

46 (15.7)

39 (30.2)*

24 (19.5)

13 (26.5)

108 (21.6)

12 (14.5)

33 (27.1)

17 (28.3)

16 (25.8)

15 (28.3)

18 (26.1)

12 (26.1)

16 (41.0)*

3 (12.5)

2 (15.4)

32 (29.6)

1 (8.3)

29 (23.8) 10 (8.2)

12 (20.0) 5 (8.3)

17 (27.4) 5 (8.1)

10 (18.9) 5 (9.4)

19 (27.5) 5 (7.3)

14 (30.4) 4 (8.7)

8 (20.5) 4 (10.3)

3 (12.5) 1 (4.2)

4 (30.7) 1 (7.7)

26 (24.1) 9 (8.3)

2 (16.7) 1 (8.3)

14 (11.5)

6 (10.0)

8 (12.9)

4 (7.6)

10 (14.5)

5 (10.9)

4 (10.3)

1 (4.2)

4 (30.7)

12 (11.1)

1 (8.3)

14 (11.5) 9 (7.4) 58 (47.5)

9 (15.0) 4 (6.7) 28 (46.7)

5 (8.1) 5 (8.1) 30 (48.4)

6 (11.3) 2 (3.8) 26 (49.1)

8 (11.6) 7 (10.1) 32 (46.4)

7 (15.2) 2 (4.4) 20 (43.5)

7 (17.9) 5 (12.8) 20 (51.3)*

0 (0) 2 (8.3) 10 (41.6)

0 (0) 0 (0) 8 (61.5)

14 (13.0) 9 (8.3) 51 (47.2)

0 (0) 0 (0) 6 (50.0)

68 (55.7)

35 (58.3)

33 (53.2)

31 (58.5)

37 (53.6)

26 (56.5)

21 (53.8)

11 (45.8)

10 (76.9)

60 (55.6)

6 (50.0)

115 (19.4)

58 (20.1)

57 (18.7)

44 (17.7)

71 (20.6)

52 (17.8)

29 (22.5)

24 (19.7)

10 (4.9)

103 (20.6)

10 (12.0)

35 (30.4)

20 (34.5)

15 (26.3)

15 (34.1)

20 (28.2)

15 (28.9)

15 (51.7)*

1 (4.2)

4 (40.0)

34 (33.0)*

0 (0)

31 (27.0) 11 (9.6)

16 (27.6) 4 (6.9)

15 (26.3) 7 (12.3)

8 (18.2) 4 (9.1)

23 (32.4) 7 (9.9)

15 (28.9) 5 (9.6)

9 (31.0) 2 (6.9)

5 (20.8) 2 (8.3)

2 (20.0) 2 (20.0)

27 (26.2) 10 (9.7)

3 (30.0) 1 (10.0)

15 (13.0)

6 (10.3)

9 (15.8)

4 (9.1)

11 (15.5)

8 (15.4)

5 (17.2)

1 (4.2)

1 (10.0)

13 (12.6)

1 (10.0)

17 (14.8) 5 (4.3) 55 (47.8)

10 (17.2) 2 (3.5) 30 (51.7)

7 (12.3) 3 (5.3) 25 (43.9)

4 (9.1) 1 (2.3) 18 (40.9)

13 (18.3) 4 (5.6) 37 (52.1)

11 (21.2) 3 (5.8) 27 (51.9)

4 (13.8) 1 (3.5) 13 (44.8)

1 (4.2) 1 (4.2) 10 (41.7)

1 (10.0) 0 (0) 5 (50.0)

17 (16.5) 5 (4.9) 48 (46.6)

0 (0) 0 (0) 5 (50.0)

64 (55.6)

35 (60.3)

29 (50.9)

25 (56.8)

39 (54.9)

31 (59.6)

14 (48.3)

10 (41.7)

9 (90.0)

59 (57.3)*

3 (30.0)

86 (74.8)

45 (77.6)

41 (71.9)

36 (81.8)

50 (70.4)

35 (67.3)

29 (100)*

13 (54.2)

8 (80.0)

78 (75.7)

7 (70.0)

23 (32.4)

8 (20.5)

15 (46.9)*

10 (35.7)

13 (30.2)

13 (48.1)

6 (24.0)

3 (25.0)

1 (12.5)

21 (32.8)

2 (33.3)

28 (40.6)

14 (36.8)

14 (45.2)

7 (25.9)

21 (50.0)*

12 (46.2)

10 (40.0)

3 (25.0)

3 (37.5)

26 (41.9)

1 (16.7)

43 (37.4)

18 (31.0)

25 (43.9)

24 (54.6)

19 (26.8)

14 (26.9)

14 (48.3)

10 (41.7)

5 (50.0)

33 (32.0)

8 (80.0)

As a result of multiple responses and omitted answers, values across categories do not always yield the same total. * Value significantly greater than other values in the category, p < .01. ^ Because of small cell sizes, the Other category was omitted from comparisons.

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Total

R.C. Goldsworthy and C.B. Mayhorn / Journal of Adolescent Health - (2009) 1–4

Base No.(%)

3

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R.C. Goldsworthy and C.B. Mayhorn / Journal of Adolescent Health - (2009) 1–4

studies that have been limited to single geographic locations and often to single schools. Items were self-reported and are subject to limitations, including social response bias. The likely impact is an underestimation of the actual prevalence of sharing behaviors and outcomes. The study found a high rate of ‘‘allergic reactions or side effects’’; however, we are not able to determine whether adolescents perceived these as positive or negative (e.g., for certain classes of drugs, the ‘‘side effect’’ may be exactly the effect they sought). Future research should consider adolescent definitions and perceptions of ‘‘side effects’’ more closely. Such efforts should also examine reasons for and sources/recipients of sharing. These are not directly addressed here and would provide important contextual information. Finally, efforts to reduce the prevalence and consequences of adolescent medication sharing may be justified, including training providers to ask specifically about borrowed medication and educating patients about proper use of prescriptions and risks of sharing. Development of messaging related to sharing, for example, within product packaging or public awareness campaigns, may merit further consideration.

Acknowledgments The research discussed herein has been supported by grant DD00001 to the first author from the National Center on Birth Defects and Developmental Disabilities (NCBDDD), a part of the Centers for Disease Control and Prevention (CDC). The article’s contents are solely the responsibility of the authors and do not necessarily represent the official views of NCBDDD/CDC. The research reported herein was approved, with a parental consent waiver, by the institutional review board of the Academic Edge, Inc. (FWA 0000439).

Richard Goldsworthy is Director of Research and Development for the Academic Edge, Inc., a research group specializing in healthcare communication and education. Christopher B. Mayhorn is an associate professor in the Human Factors and Ergonomics Psychology Program at North Carolina State University. References [1] Goldsworthy RC, Schwartz NC, Mayhorn CB. Beyond abuse and exposure: framing the impact of prescription medication sharing. Am J Public Health 2008;98(6):1115–21. [2] Petersen EE, Rasmussen SA, Daniel KL, et al. Prescription medication borrowing and sharing among women of reproductive age. J Womens Health 2008;17(7):1073–80. [3] Mitchell AA. Prescription medication sharing. Am J Public Health 2008;98(11):1926–7. [4] Boyd CJ, Esteban McCabe S, Teter CJ. Medical and nonmedical use of prescription pain medication by youth in a Detroit-area public school district. Drug Alcohol Depend 2006;81(1):37–45. [5] Daniel KL, Honein MA, Moore CA. Sharing prescription medication among teenage girls: potential danger to unplanned/undiagnosed pregnancies. Pediatrics 2003;111(5 Pt. 2):1167–70. [6] McCabe SE, Boyd CJ, Young A. Medical and nonmedical use of prescription drugs among secondary school students. J Adolesc Health 2007;40(1):76–83. [7] Poulin C. Medical and nonmedical stimulant use among adolescents: from sanctioned to unsanctioned use. Can Med Assoc J 2001; 165(8):1039–44. [8] Boyd CJ, McCabe SE, Cranford JA, et al. Prescription drug abuse and diversion among adolescents in a southeast Michigan school district. Arch Pediatr Adolesc Med 2007;161(3):276–81. [9] Wysowski DK, Swann J, Vega A. Use of isotretinoin (Accutane) in the United States: Rapid increase from 1992 through 2000. J Am Acad Dermatol 2002;46(4):505–9. [10] Goldsworthy RC, Kaplan B. Warning symbol development: A case study on teratogen symbol design and evaluation. In: Wogalter MS, ed. Handbook of Warnings. Mahwah, NJ: Lawrence Erlbaum, 2006:739–54.